DEAD END

When I moved to Oregon, I volunteered for organizations I didn’t even know existed, and I didn’t volunteer, but thought I would, for others. Such is life, and I predicted this experience before the move. When I learned there was a state-wide reporting system for medical errors, I wrote them, eventually being invited to their offices to meet with the staff. I was optimistic.

But not surprisingly, nothing came of it. I knew that when I walked out the door after that meeting. I read body language well. I saw the expression, “I’m really busy and need to get back to work rather than talk to this guy.” What I brought, they didn’t need, and that is OK, just unfortunate for me. I later wrote an opinion piece about the need for pharmacies in the state to do more analysis of the errors they made, so that we could improve state-wide systems. Seven hundred pharmacies in the state generated only 20 reports last year. That’s disappointing, but again not surprising, either. Nothing came of my article, but I didn’t expect anything. I’ve gone down a lot of dead-end roads. I turn around and try others. Occasionally, I find a path that leads to interesting places. I don’t find one often, but if I don’t try, I won’t find it at all.

After a few problems obtaining my medication, which I recently wrote about, I sent a letter about my experiences to the head of the Patient Safety Commission. I didn’t know what would happen, but again, if I didn’t write, nothing would happen. I received a reply, saying my letter was forwarded to the staff as a reason why the Commission exists. I found that Interesting. A few days later, a staff member wrote me saying she knew a man who taught pharmacy students, and he might be interested in talking to me. This road was going a little further than I thought. After exchanging a few emails, the pharmacist called me and we spoke about medical errors, pharmaceuticals, and other issues.

It wasn’t a fit, and before I heard the words, I knew this wasn’t going to work out. I can read body language over the phone well, too. He wanted somebody “downstream,” a patient who could come to his class and explain how a medication error affected them. That’s asking for a lot, and I think is unrealistic. I sure couldn’t provide it. I saw the Dead End sign, but we had an interesting talk. I think his class would benefit from one who had seen a lot of errors in other fields, studied them, and could advise his students about system design and learning from errors. Somebody like me.

For a couple of hours after the call, I had the usual down in the dumps feeling, which happens when I encounter a dead end sign. Maybe something will happen. He might talk to other people who are interested in what I have to say. But I strongly doubt it. It almost never happens. Networking to me has led only to my giving free advice, almost never receiving anything in return. Still, I keep trying, although I am running out of time.

I might have told the students about the error in a Bend hospital, where a lady after recent brain surgery came to the hospital and had fosphenytoin, an anti-convulsant, ordered. For some reason, she was given an IV bag containing rocuronium, a paralytic, but labelled as fosphenytoin. She might have survived had there not been a Code Red, for fire, and was left unattended for 20 minutes. She died a few days later from anoxic encephalopathy. It’s like a plane that has a landing gear problem that consumes the pilot’s attention so much that the plane runs out of fuel and crashes. That happened in Portland in 1978, killing 10. It spawned CRM, Crew Resource Management, which essentially considers everybody in the cockpit an equal resource in an emergency. The concept worked a decade later on a United jet and to perfection in 2010 when a Qantas A-380’s port engine exploded and the plane had to be nursed back to Singapore. The video is worth seeing, as an example of how teamwork in the cockpit saved the plane and all aboard. The investigation is worth reading, as well, as to how a seemingly minor quality assurance problem at Rolls-Royce had catastrophic results. Oh, it wasn’t a miracle that everybody survived. A miracle would be not to have had a problem ever occur with anything we make. Everybody survived because of redundancies built into the aircraft and skill of the crew. Medicine needs that kind of dedication to safety, where pharmacists are important resources who can find errors in drug choice, dosage, or interactions.

Instead, I read online that there now needs to be a safety zone where those mixing drugs will not be interrupted. I’ve been harping on that for 15 years. Sterile cockpit means that nobody talks about anything but the aircraft when the altitude is below 10,000 feet. In 2013, exactly four cases of incorrect medication being given were reported state-wide. Whatever the number, we aren’t learning from them. I later read that up to 440,000 deaths in the US occur from medical errors annually, and I don’t believe that number, either, because if we can’t even track something simple like the wrong medication’s being given, we can’t possibly know the number of medical errors. I offered a solution a decade ago, one that uses random sampling of hospitals, but I hit a Dead End sign.

I could have spoken to the students about our needing to count the number of prescriptions filled improperly, the number of prescribing errors made, and the number investigated, not to shame anybody, but to understand how many errors and what kinds of errors are made, so we could refine systems and know whether or not we had refined them successfully.

I think with examples compared to aviation, which I find compelling, we could start educating students the need to have a safe, effective, voluntary way to report safety issues. Maybe that generation would stand on my shoulders and see further than I.

No, I have spoken out on the topic enough, maybe too much. I’m out of date, but there are things still happening that shouldn’t be. A patient was recently awarded over $12 million from being given the wrong dosage of Amiodarone during a procedure. He is now brain-damaged for life. This was a preventable error. For him, normal life hit Dead End.